ST.
MARY’S DANCE ACADEMY, INC. 2019 – 2020 REGISTRATION FORM
( 25.00 returning students/35.00
Family, 30.00 new students/40.00 Family) - form can be emailed to stmarydance@yahoo.com - pls state payment in mail - or mail payment and form to SMDA, P.O. Box 314 Valley Lee MD, 20692. Tuition is due first day of class. Non -Refundable registration fee holds your space in the class.
Please fill out one for each
child
Student Name:
_______________________________ Age:________ DOB:___________
If
under 18 – Parent/Guardian Name: __________________________________________
Relationship
to Student: ______________________
Mailing Address:
___________________________________________________________
Where Did
You Hear About Us? ___________________________________
Home Phone: ________________ Work
Phone: __________________ Cell:___________________
Please
print legibly, as this is our main form of communication.
Email: ________________________________
Alternate email or phone _______________________
Classes registering for:
example:
Class:
Cheer (5 – 7 yr) Day/time Monday 6:00 – 6:45
Class
_____________________
Day/time ________________________
Class
______________________ Day/time
________________________
Class
______________________ Day/time
________________________
Class
______________________ Day/time
________________________
Tuition
is due on the first day of class of each month. A 15.00 late fee is imposed if
tuition is more than 7 days late. After
the 10th of the month the late fee is automatically added on – see student
handbook.
WAIVER AND RELEASE OF
CLAIMS. Parent/Guardian and dancer
recognize there is a risk of injury in any type of dance/sport program. Parent/Guardian acknowledges that the student
is participating upon his/her express agreement that injury may occur and
agrees to release St. Mary’s Dance Academy Inc., its employees, directors,
volunteers from any and all liability relating to any accident. St. Mary’s Dance Academy Inc. does not carry
medical insurance for students. All students
are required to be covered by their own family health insurance in the event of
sickness or an injury. As the
parent/guardian/student, I accept the financial responsibility for treatment of
the student should the need arise during any and all St. Mary’s Dance Academy
Inc. programs. I agree not to hold St.
Mary’s Dance Academy Inc., and any assigned representative financially
responsible for the care or treatment that may be needed. I hereby waive and absolve St. Mary’s Dance
Academy, Inc. of any liability and responsibility for injuries, damages, or
losses incurred during participation of any and all programs, activities,
events associated with St. Mary’s Dance Academy, Inc. by myself and/or
child.
Date______________________ Printed Name (of person signing):
____________________________
Signature ____________________________________( Signature of
Parent/Guardian – if under 18 years.
Signature of student if 18 years or older.
